Aug 13 2012
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In Aurora, A Massacre Becomes a Miracle, and Then Patients Help Doctors Heal

Comilla Sasson, MD, MS, is an attending physician at the University of Colorado Hospital and Assistant Professor in the Department of Emergency Medicine at the University of Colorado.  Sasson was a Robert Wood Johnson Foundation (RWJF) Clinical Scholar at the University of Michigan from 2007 to 2010.

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I wasn’t even supposed to work that night. I had finished a long day of meetings, and found out at 6:30 pm that my colleague, who had called in sick twice in 40 years, had influenza and he knew it was best not to expose Emergency Department (ED) patients to it.  After he called, I remember thinking, “Well, I can just power through until 8 am. Nothing too bad happens on Thursday nights.”

The night began as many other nights do in our ED. Twenty-five of our 50 beds were taken up by inpatients who were waiting for hospital beds to open up.  The ED was completely full, with another 10 patients in the waiting room. “Another one of those nights,” I groaned to myself.  We were already on “divert” status, meaning that ambulances would bypass our hospital and go to others in town. This should be a relatively easy night, right?

Until we received the call over the dispatch radio at approximately 12:30 am: Shooting at a theater in Aurora. Hopefully the paramedics remembered we were already at capacity and took the patients elsewhere.  Nine minutes later, we received a frantic phone call from one of the policemen on scene: Multiple shooting victims and Aurora Police Department just received permission to transport patients to hospitals in the backs of police cars instead of waiting for ambulances.  That’s when we realized this was not a gang fight with one or two victims, this was something different. 

The first police car showed up at 1:06 am. We raced out to the ambulance bay and started removing patients from the back of the car. The police car looked like a crime scene, with blood splattered throughout. As we were pulling the first two victims out of the car, another police car showed up. And another. And another. In total, we received nine police cars and one ambulance within 45 minutes.  Looking out into our ambulance bay with police lights flashing, I realized, this is not like any other shooting I have been involved in. This is radically different.

Coordinated Chaos
I know how to treat multiple trauma patients. I had done my residency training in Emergency Medicine at the only Level One trauma center in Atlanta.  But nothing in my career could have possibly prepared me for that Thursday night. The sheer magnitude of the number of patients, and how critically injured so many of them were, allowed us only to function on adrenaline and instinct.  There was no time to think. 

As the attending ED physicians, my colleague and I had stationed ourselves in the ambulance bay so that we could assess how critically injured each patient was as he/she was pulled from the back of the police car. Our ED administrative staff had activated our Plan D, and we were officially in disaster mode. Operating rooms were opened, attending surgeons were called in, and nursing staff raced down to the ED. A quick-thinking medicine resident paged her colleagues and told everyone who was in house to come down to the ED immediately.

The patients came quickly, and we had no information about their status before they arrived. We had two resuscitation bays that each hold one person.  But that night, we were running a chess game out of the resuscitation bays and the MASH unit we had created between the ambulance bay and the resuscitation area, rotating our nine most critically injured patients in and out of the resuscitation area so we could place them on ventilators or put tubes in their chests to drain their lungs of blood.

We cared for victims with bullets through the head, chest, abdomen, neck and extremities. It was coordinated chaos and my colleague and I were the chess players, having to think 10 moves ahead to ensure that the sickest patients were being placed on the ventilators first. We put one resident in charge of one to two patients and instructed them to report back to us every five minutes. Bullet wounds are challenging to care for, because what you see isn’t what you get.  A bullet wound to the shoulder can end up in the abdomen, wreaking havoc and creating internal bleeding depending on its trajectory. Monitoring vital signs closely and constantly reassessing the patient was so essential. We needed to make sure that nobody was crashing—blood pressure dropping, becoming unresponsive—all of which can happen in seconds.

In total, 23 patients showed up on our doorstep within two hours of the incident, with little to no warning. Five were placed on the ventilator, seven had chest tubes placed to drain the blood from their lungs, six went to the operating room within a few hours of arrival, and four others with orthopedic injuries went later that morning. Our amazing group of surgeons spent all night and morning taking care of these patients. A relay of sorts, as the surgeons took the baton from us in the ED, where we stabilized the patients so that they could be transported up to the operating room for their life-saving surgeries.

Hospitals are families, and the ED may be even more so. We came together that night to treat patients who needed us—made all the more difficult because in some ways, they were a lot like us. The patients we treated that night ranged from four months to 50 years old, with the vast majority being between the ages of 16 to 30.  A lot of us were thinking that if we hadn’t been working that night, like them, we might have been at that movie theater.

To me, the police officers who brought patients in so quickly were unsung heroes. At first they were the targets of some criticism for not waiting for paramedics in ambulances to transport the patients. But now, more people understand how smart their actions were. In trauma, we talk about the “golden hour”—the first hour after a traumatic injury that often determines whether a person will live or die. Getting these patients to the hospital quickly, during the golden hour, literally saved our patients’ lives. That is something first responders in Colorado, in particular, understand well, because of the lessons learned from Columbine, where many victims bled out and died while waiting three hours for the scene to be secured.

It wasn’t until about 3 pm on Friday, the next day, when I finally took a moment to think about what we had faced, what we accomplished, who we saved. I am proud that every single patient who arrived with a pulse that night, is still alive today.  Twenty-two victims of the 23 total we received.  It truly is the “Aurora Miracle,” considering the extent of injuries, the sheer number of people coming in so quickly, and the fact that everyone is alive today.

Many of us had to return to work that same night, pretending that it was business as usual. So many of us were unable to sleep because the last visions we had of many of our patients were of intestines hanging out, ventilators beeping, chest tubes draining, and bullets in heads and necks.  But what haunted us most was that once these patients left our ED, we didn’t necessarily even know their names or if they were alive.

From Grief to Recovery
In the days following the incident, our ED family has grown stronger and closer as we all realized that each of us was hurting. We are “hardened” ED folks. We see tragedy every day and still manage to separate ourselves from the emotions. However, at the end of the day, we are still human. Compassion, empathy and extreme sadness are not emotions we routinely discuss in the ED. But for the last two weeks we have.  We have come together to debrief and to cry. Sometimes at inopportune moments, the emotions come out.

I think that now, many of us are finally on the other side of it, moving from the grief to recovery.  One reason is our patients. Just days after the incident, I led a group of the ED staff upstairs to visit with one of our victims. The first patient we visited was younger than anyone on the ED staff who had cared for her. But when we walked into her room, despite her pain and fear, she looked up, recognized some of us and said, “Give me a hug.” We were all sobbing, finding solace and comfort in the fact that she was alive, her family was surrounding her, and the amazing resilience and spirit she embodied in the wake of this tragedy. Her smile, and family surrounding her are the visions that have replaced the horrific ones from that night. The patients we helped are now healing us in the wake of this tragedy.

During these last two weeks, I have felt enormous anger and great sadness at the lives completely changed in an instant. Working in the ED, we are constantly reminded of our own mortality, of how fragile life is, and that everything can change in a second. That night has inexplicably changed each one of us forever. Having never been through war, but hearing my colleagues who have, describe how similar this experience is to what they have experienced in Iraq and Afghanistan, I have a new found appreciation and admiration for our veterans, many of whom are my age.

Around the city, 12 people died that night—but there could have been hundreds dead. So when people talk about the Aurora massacre, I think about the “Aurora Miracle” and how many lives were saved. I am proud to be part of this community and am committed to it. 

I am proud to be part of the Robert Wood Johnson Foundation “family,” too.  It was when I was training at the trauma center in Atlanta that I met Art Kellermann, MD, MPH, FACEP, who told me about the RWJF Clinical Scholars program. I fell in love with the idea of doctors who didn’t just treat those who are sick or injured, but are dedicated to making their communities healthier. And it was Richard D. Krugman, a member of the Clinical Scholars program’s National Advisory Committee and the dean of the University of Colorado School of Medicine, who convinced me to come to Colorado. 

Everything happens for a reason. I truly believe that the series of events that have led me to come to Colorado, with no family and a few friends, but a strong belief that this is where I need to be, have transformed my perspective on life. The RWJF Clinical Scholars program has taught me that the most important thing I bring to the table in my research is the clinical experiences I have had, and how this can be extremely powerful. 

This campus, which includes the hospital, used to be an army base—but I dare say it never saw as much trauma as we experienced that night. It was the most tragic thing I hope I’ll ever see. My research has been on improving health disparities in those communities that need it the most. On that tragic night, it was the entire community of Aurora that needed us. I am proud of what we accomplished and proud to be part of this community.

Learn more about the Robert Wood Johnson Foundation Clinical Scholars program.

Tags: Clinical Scholars, Colorado (CO) M, Emergency Care, Emergency care, Human Capital, Inpatient care, Local or community-based, Medical, Nursing & Dental Workforce, Physicians, Voices from the Field